GPs and Consultants : is there Agreement on Patient Management ?

General practitioner attitude questionnaires were sent in May 1987 to 525 general practitioners (GPs) within Avon. A year later a section dealing with the management of clinical situations was sent to 198 Avon consultants, to determine how they would ideally expect a GP to respond to these situations. The majority of both the GPs and consultants held a common viewpoint, but significant differences were noted between the consultants and GPs in six out of the ten situations. Consultants with more than six months' GP experience had fewer significantly different views than their colleagues with little or no GP experience. GPs and specialists under the age of 45 years also had fewer significant differences in management than older GPs and specialists. The differences seem to reflect the clinical focus and interests of each professional group. We believe vocational training is a contributory factor to the differences and support the General Medical Council's proposal of a broader post registration training for all doctors.


INTRODUCTION
Patient welfare needs full co-operation between hospital and community sevices. This co-operation in turn depends on collaboration between specialists and general practitioners and has implications not only for high quality patient care but for referral and, ultimately, health authority costs [1]. At present, specialists and general practitioners principally come into contact during the processes of referral and education.
Variations in GPs' rates of referral are still a matter of concern, with no conclusive explanation yet found. Cummins ct al [2] suggested that doctors have unique 'referral thresholds', and other studies have suggested that diagnostic uncertainty as indicated in Dowie's model of referral [3] is only one aspect of a complex referral decision [4]. Further studies into qualitative aspects such as the 'appropriateness' of GP referrals in terms of how far GPs', consultants' and patients' expectations are met are suggested by Roland [5], Yet, consultants' involvement in the referral process has been little studied. General practitioners made only fifty-four per cent of the referrals in an outpatient study [3]. Hospital doctors were responsible for the remainder, which included discharged inpatients and referrals from other consultants. Medical training is mainly hospital based with, more recently, a period in general practice for all students. Since 1982, intending general practitioners have been required to spend two years in hospital training posts and a year as a trainee in general practice. No

Subjects
In May 1987, a general practitioner attitude questionnaire was sent to all 525 general practitioner principals in Avon [7]. Of these, 424 (81%) replied and, excluding practices with restricted list sizes or too few patients in Avon, a final 371 GPs (71%) were entered in this study, which occurred a year later.
To gain consultants' views, the section presenting ten clinical situations and their possible management was sent in July 1988 to 198 clinical consultants employed in four Avon health districts. They were asked how they ideally would expect the GP to answer. Completed questionnaires were received from 166 (84%) of the consultant sample. The distribution amongst the four districts is illustrated in Appendix A and amongst specialties in Appendix B.
There were 250 GPs and 61 consultants under 45 years, 121 GPs and 105 consultants aged 45 years and over. Eighty-four per cent of those consultants with more than 6 months GP experience (25), were in the 'older' consultant sample, but only represented 20% of the total number of consultants 45 years and over. There were 12 female consultants (7.2%); the GP sample included 81 women (21.8%).

Methods
The GPs were asked to indicate how they would manage 10 clinical situations (scenarios), and the consultants asked how they would ideally expect the GP to manage them, by marking one of four alternatives (Appendix C). The options may be summarised as: (1) Treating symptomatically and/or waiting for the patient to return if necessary; (2) Treating and/or investigating; (3) Treating and/or investigating more extensively; (4) Referring. Scenarios 1,3,8,9, 10 are examples of low risk situations (e.g. scenario 8. Recent onset of colourless, non-offensive vaginal discharge in a menopausal woman. Vaginal examination and speculum examination NAD). Scenarios 2, 4, 5, 6, 7 are higher clinical risk situations because of the patient's age or description of illness (e.g. The results were collated and analysed with Kruskall Wallis non-parametric analysis of variance, comparing the answers of: (1) GPs with consultants; (2) GPs with consultants who had more than 6 months general practice experience; (3) GPs with consultants who had no or only locum GP experience; (4) GPs and consultants under 45 years old; (5) GPs and consultants aged 45 years and over.

RESULTS
The majority of doctors (GPs and consultants) tend to agree on the method of clinical management. Despite this, significant differences emerge. Overall, these differences are because the GPs choose a more conservative management approach, preferring to wait or treat symptomatically (towards option 1) and the consultants expect the GPs to investigate extensively or refer (options 3 or 4).
The consultants with more than 6 months' GP experience differ from the GPs in scenarios 5, 6 (P<0.01) ( Table 2).
Those with no or only locum experience differ in scenarios 5, 6, 7 (PC0.01) and 2, 4 (P<0.05) ( Table 3). Therefore, consultants with general practice experience have fewer significant differences to GPs than their colloeagues with no or only locum experience. GPs and consultants under the age of 45 years differ in scenarios 5, 7 (P < 0.01) where a higher percentage of GPs are again choosing to wait (towards option 1) and more consultants expect extended investigations or referral (Table 4). This tendency is more extreme in their older colleagues who differ in scenarios 2, 5, 6, 7 (P<0.01) ( Table 5). Younger GPs and consultants in this study, therefore, had fewer significant differences than older GPs and consultants. All results are in percentages Table 1 Comparison of Replies to Scenarios 1-10 between GPs and Consultants with more than 6 months GP Experience

DISCUSSION
The interest of this study lies in the similarities or otherwise of a group of GPs and consultants. It is reassuring to find that the main body of GPs and consultants agree on the chosen method of management. Some of the divergence in replies may be explained by the brevity of the scenarios and the limitation of management options. Yet, significant differences were found in a considerable proportion (6/10) of the scenarios. We feel the recognition of these differences is important; they may reflect a lack of understanding between the two parts of the profession to the detriment of effective patient care and efficient use of resources.
The results showed that consultants differed from the GPs by not expecting them to rely on the patient to return if the symptom persists or treat without extensive investigations. Also, the situations where significant differences were shown between GPs and consultants were usually higher in clinical risk. We therefore feel that some of the differences arose through consultants' hospital based training and associated higher incidence of serious pathology leading them to expect extensive investigatons or referrals. Although the sample is small, the fact that consultants with six months general practice experience, and both GPs and consultants under 45 years old (who usually have had undergraduate GP experience) have fewer significant differences to GPs than their less GP-experienced or older colleagues strengthens this point.
Our study showed a tendency for specialists to be more in accord with GPs when answering questions specific to their specialty. Unfortunately, when broken down into specialties, the sample sizes were too small for statistical analysis, and this tendency needs testing with larger samples. Several of the consultants were understandably apprehensive about answering questions on problems outside their specialty. However, from time to time they may be faced with this situatin and be required to make management decisions. They may then refer to specialist colleagues rather than refer the patient back to the general practitioner. The appropriate management decision in some way depends on the doctor's awareness of the available options (GPs now have statutory vocational hospital experience but few consultants have received postgraduate experience of general practice), and on the cooperation of the parties involved.
As one means, therefore, of improving collaboration between primary and secondary health care, we support the GMC's proposal of a broader training, and advocate a period of at least six months general practice experience as part of a clinical specialist's vocational training. The advantages of postgraduate general practice training for all clinicians would include experience of the incidence and pathology of common diseases, a more holistic and preventive approach to illness and demonstrate the GPs' role in providing follow-up care.